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long term disability specialist resume example with 8+ years of experience

Jessica Claire
  • , , 609 Johnson Ave., 49204, Tulsa, OK 100 Montgomery St. 10th Floor
  • H: (555) 432-1000
  • C:
  • resumesample@example.com
  • Date of Birth:
  • India:
  • :
  • single:
  • :
Professional Summary

Service-oriented Claims Adjuster skilled at applying creative approaches to solving complex problems. Negotiates peaceful resolutions of all claims with emphasis on fairness and thoroughness. Trustworthy and dependable.

Skills
  • Quality Customer Service
  • Time Management
  • Accident Investigations
  • Medical Terminology
  • Claims File Management Processes
  • Advanced Oral and Written Communication Skills
  • Interviewing Techniques
  • Insurance Industry Experience
  • Negotiate Settlements
  • Insurance Coverage Verification
  • Documentation Review
  • Workers Compensation Claims
  • Proficient In Microsoft Office Suite
  • Policy Understanding
  • Coverage Assessments
Work History
Long Term Disability Specialist, 05/2021 - 02/2022
City Of Jacksonville, Fl Jacksonville, FL,
  • Reviewed and processed increasingly complex assigned claims for payment or denial independently in accordance with established procedures and guidelines, in a timely manner and meeting departmental quality/production standards
  • Interacted with claimants to ensure awareness and understanding of the Long-Term Disability escalation process, requirements, and entitlements
  • Conducted comprehensive interviews of witnesses and claimants to gather facts and information
  • Responsible for employer Long Term Disability contract review
  • Developed and maintain internal systems for data collection
  • Responsible for managing clerical duties for all assigned escalated Short-Term Disability and Long Term Disability Claims
  • Managed 100 claims in pended or approved status
  • Demonstrated ability to use sound judgment and discretion regarding confidential information
  • Maintained strong knowledge of basic medical terminology to better understand services and procedures
  • Clinical claim consultations to assess initial and ongoing claims management
  • Directed and coordinated various investigations conducted by field investigation team
  • Substantiated legitimate claims and denied unjustified claims.
  • CSR for Lincoln Financial Group
  • Reviewed police reports, medical treatment records and physical property damage to determine extent of liability
  • Actively listened to customers, handled concerns quickly and escalated major issues to supervisor
Claims Assistant, 03/2016 - 04/2018
Sedgwick CMS City, STATE,
  • Adjusted medical-only claims and minor lost-time workers compensation claims
  • Interacted with claimants to ensure awareness and understanding of the workers compensation process, requirements, and entitlements
  • Ensured claim files were properly documented
  • Coordinated medical treatment for injured employees and provided information to treating physicians regarding employee’s medical history, health issues, and job requirements
  • Served as a liaison between medical providers, employees, employers, and government agencies
  • Inform departments of injured employee’s work restrictions and coordinate appropriate accommodations
  • Processed routine payments and status reports for lifetime medical claims and/or defined period medical claims
  • CSR for Sedgwick CMS Columbia
  • Processed workers compensation claims determining compensability and benefits due
  • Monitored reserve accuracy, and filed necessary documentation with state agency
  • Developed and maintain internal systems for data collection and entry, financial analysis, and diary as necessary
  • Responsible for managing clerical duties for 500 Lost Time claims
  • Examined reports, accounts and evidence to determine integrity and accuracy of information
  • Worked productively in fast-moving work environment to process large volumes of claims
  • Modeled exceptional customer service skills
  • Oversaw claim recoveries and subrogation
  • Posted payments to accounts and maintained records
  • Maintained strong knowledge of basic medical terminology to better understand services and procedures
  • Followed up with customers on unresolved issues
  • Prepared insurance claim forms or related documents and reviewed for completeness
Senior Workers Compensation Examiner, 07/2007 - 03/2011
Florida Department Of Financial Services City, STATE,
  • Entered, recorded, and reviewed claims into claims information management system
  • Processed routine claims transactions related to reserves
  • Utilized outstanding communication and interpersonal skills to maintained strong and positive relationships with providers, claimants, and lost time adjusters
  • Performed verification checks on customer/claimant loss-claims following Bureau standard policies and procedures
  • Responsible for managing clerical duties for three state agencies.
  • Managed 300 low touch medical only claims
  • CSR for Workers Compensation claims department
  • Reviewed new files to determine current status of injury claim and to develop plan of action
  • Evaluated original investigation reports and documents to resolve secondary concerns
  • Reviewed Incident reports, police reports and medical treatment records to determine extent of liability
  • Researched claims and incident information to deliver solutions and resolve problems
  • Conducted comprehensive interviews of witnesses and claimants to gather facts and information
  • Maintained contact with claimants and medical providers to determine treatment status
  • Delivered exceptional customer service to policyholders by communicating important information and patiently listening to issues
  • Analyzed information gathered by investigation and report findings and recommendations
Claims Examiner/ Senior OCR Operator, 03/2003 - 02/2005
AmeriHealth Administrators City, STATE,
  • Adjudicating medical and dental claims
  • Monitoring claims and reviewing for accuracy
  • Responsible for key contextual and update edits on fields not passing programming edits at a performance rate of 100%
  • Keyed video repair and reject re-entry corrections on unscannable data elements with 100% performance rate
  • Data Entry 10-Key Numeric 10,000 KPH and Alpha Numeric
  • ICD-9 Coding
  • Corrected CPT codes to properly classify Medical and Dental claims
  • Maintained knowledge of benefits claim processing, claims principles, medical terminology and procedures and HIPAA regulations
  • Managed large volume of medical claims on daily basis.
  • Paid or denied medical claims based upon established claims processing criteria
  • Collaborated with claims department and industry anti-fraud organizations to resolve claims
Education
Associate of Arts: General Studies , Expected in 12/2003
-
Florida Community College - Jacksonville, FL,
GPA:
Status -
Certifications
  • Licensed SC All Lines Insurance Adjuster 2015-2019
,

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Resume Overview

School Attended

  • Florida Community College

Job Titles Held:

  • Long Term Disability Specialist
  • Claims Assistant
  • Senior Workers Compensation Examiner
  • Claims Examiner/ Senior OCR Operator

Degrees

  • Associate of Arts

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